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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case report
Year : 2012 | Month : May | Volume : 6 | Issue : 3 | Page : 465 - 468 Full Version

Bilateral Musculus Sternalis: A Case Report


Published: May 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.1950
Rajan Kumar Singla, Kanika Sachdeva

1. MBBS, MS (Anatomy), Additional Professor, Department of Anatomy, Government Medical College Amritsar, Punjab, India. 2. MBBS, MS (Anatomy) Assistant Professor, Department of Anatomy Chintpurni Medical College & Hospital Dalhousie Road, Bungal-Pathankot Punjab, India.

Correspondence Address :
Dr. Kanika Sachdeva
Chander Niwas, 61, Lawrence Road
Amritsar, Punjab, INDIA
Phone: +91-9888284878
E-mail: kanikadr.sarang@yahoo.com

Abstract

The finding of the sternalis muscle is a rare entity of the anterior chest wall that challenges our understanding of the anatomy of the parasternal region. When it is present, it lies superficial to the pectoralis major and parallel to the sternum, and it extends from the jugular notch to the costal region. In the present study, a bilateral case of the sternalis muscle has been reported, which was noticed in a 60-year old male cadaver. On both the sides, the muscle was extending from the level of the sixth costal cartilage to the front of the manubrium sterni and it was even continuing with the ipsilateral sternocleidomastoid. This rare anomaly has puzzled radiologists and surgeons with respect to the confirmation of its diagnosis, where there was a chance of missing it all together or mistaking it for tumour on mammography or CT scan. The sternalis muscle may be important for reconstructive surgeons who perform mastectomy and for radiologists who interpret mammograms. Thus, the sternalis muscle is academically, anthropologically and surgically important.

Keywords

Sternalis, Pectoralis major, Aponeurosis, Mammography, Breast Tumour

Introduction An unusual variation creates interest among anatomists, but it is a cause of concern among clinicians when it mimics the pathology (1). One such anatomical variant of the anterior thoracic region musculature is the sternalis muscle, which is well documented and familiar to anatomists but which is quite unknown among the clinicians and radiologists (2). It is located sub-cutaneously over the pectoralis major and it ranges from a few short fibers to a well formed muscle, lying parallel to the sternum, and extending from the jugular notch to the costal region (1). The sternalis muscle was first coined by Cabrolius in 1604 and subsequently by Du Puy in 1726. The first report by Roubinowitch in 1888, described it in live subjects (3). Subsequently, it has been termed variably as ‘episternalis’, ‘presternalis’, ‘sternalis brutorum’, ‘rectus thoracis’, ‘rectus sterni’, ‘superficial rectus abdominis’, ‘japonicus’ (4) abdomino guttural, abdomino cutaneous and cutaneous pectoris (5). Although it was first described about four centuries ago, its origin is still unclear. While some authors opine that it originates from the adjacent muscles such as the sternocleidomastoid, the rectus abdominis and the remnant of the panniculus carnosus, etc, (6) others believe that it is derived from the pectoralis major muscle (7). The muscle sternalis has been reported in either sex, and in blacks, whites as well as Asians (8),(9). Its incidence in various ethnic groups ranges from less than 0.5% in the Taiwanese to 17.3% in the Chinese (9). In the clinical practice, it is essential for the radiologists and the surgeons to acknowledge this anomaly as it may pose a diagnostic dilemma, by mimicking a malignant breast mass on mammography, CT scan or MR imaging and thus an unnecessary exploratory surgery can be avoided (1). Additionally, it provides potential surgical Case Report benefits as it can be used as a flap in the reconstruction surgery of the head and neck, the anterior chest wall and the breast (6).

Case Report

During the routine undergraduate dissection of the thoracic region in a 60-year old male cadaver, a bilateral sternalis muscle was seen (See (Table/Fig 1) & (Table/Fig 2). The left sternalis muscle, at its inferior end, was attached laterally to the sixth costal cartilage (A1) but medially, it formed an aponeurosis which merged with the fascia over the xiphisternum (A2). Beginning from the level of the sixth costal cartilage, the belly extended upwards and medially and became tendinous at the level of the third costal cartilage. It continued upwards further and medially for its superior attachment, where it gave off six slips- (i) One medial most slip in front of the sternal angle (A3) (ii) Two slips to the anterior surface of the manubrium (A4 and A5). (iii) A fourth slip which was continuous with a fellow of the opposite side. (A6) (iv) A fifth slip which was continuous with the sternal head of the ipsilateral sternocleidomastoid muscle (A7). On the other hand, the right sternalis gave off five slips at its inferior end, which were attached as follows-
(i) One lateral slip merged with the pectoral fascia (B1) (
ii) A second slip merged with the fascia over the xiphisternum (B2)
(iii) A third slip was attached to the anterior surface of the seventh costal cartilage (B3) (iv) A fourth slip was attached to the anterior surface of the sixth costal cartilage (B4). The aponeurosis formed a belly at the level of the fifth intercostal space. The belly extended upwards and medially and formed a tendon at the level of the third costal cartilage. (v) A slip from the belly went laterally to merge with the pectoralis major muscle (B5). Superiorly, the muscle showed three attachments which were as follows: (
i) One lateral most slip was merging with the pectoral fascia at the level of the second costal cartilage (B6)
(ii) A second medial most slip was attached to the front of the manubrium sterni (B7)
(iii) The middle fibers went upwards and bifurcated (B8). Out of these, the right half joined the sternal head of the ipsilateral sternocleidomastoid muscle (B8 (i)), while the left half joined the sternal head of the left sternocleidomastoid muscle (B8(ii)).
Nerve Supply: Both the sternalis were supplied by the perforating branches of the anterior cutaneous nerves.

Discussion

The sternalis muscle, an uncommon anatomical variant, located superficial to the pectoralis major; has been reported both in males and females; and in blacks, whites and Asians with a frequency which ranges from < 0.5% in the Taiwanese (9) to 23.5 % in the Chinese (10). All the studies which were done were silent about its bilateral presentation, except the findings of Raikos et al (2), which reported it to be present bilaterally in 1.7 % of the dissections. Such a high variability in its prevalence rates has been reasoned out by Jelev et al (4), due to the existence of small ill defined muscles or tendinous fibers which may or may not be accepted for the sternalis muscle. They threw a flood of light on the earlier literature and suggested that to accept a muscle as the sternalis, it had to have the following criteria:
1. Location between the superficial fascia of the anterior thoracic wall and the pectoral fascia.
2. Origin from the sternum or the infraclavicular region.
3. Insertion into the lower ribs, the costal cartilages, the rectus abdominis sheath or the aponeurosis of the external oblique.
4. Innervation by the intercostals or the pectoral nerves
On the basis of the morphology of the muscle bellies and its ‘uni’ or ‘bi’ laterality, Jelev et al (4) classified the sternalis muscle into the following types:
Type I: Unilateral sternalis muscle
1. Simple unilateral belly
2. Two or more unilateral bellies.
3. Muscle belly crossing the median line.
4. Unilateral belly passing into another muscle or into a well defined muscle bundle of any of these muscles:
• preclavicularis medialis
• sternocleidomastoideus
• pectoralis major
Type II: bilateral sternalis muscle
1. Two simple symmetric bellies
2. Two simple asymmetric bellies
3. Two bellies which were connected with the pectoralis major on the same side
4. Two bellies: one simple unilateral and the other one which was connected with both the left and the right pectoralis major muscles.
The sternalis muscle which was seen in the present cadaver didn’t fit completely into any of the above types. Firstly, it was a bilateral case and so it had to be of Type II, but since it was continuous with the sternocleidomastoid on both the sides (Slip No. A7 and B8 in (Table/Fig 1)), with the pectoralis major on the right side (B5 in (Table/Fig 1)) and with the pectoralis fascia on the left side (A8 in (Table/Fig 1)), it was thought to be unique and it remained unclassified as per the above classification. So, we propose to modify the above classification by adding another type II-5 which consisted of two bellies which were continuous with the sternocleidomastoid above and with the pectoralis major below, as was seen in the present case.
The function of the Sternalis:
The sternalis muscle has no known function. Generally speaking, when a muscle contracts, the insertion is pulled by the origin. Therefore, the contraction of the sternalis, because of its particular location, could elevate the lower chest wall, an action which was achieved by other muscles in those without it. Thus, the sternalis, at the most, played only an accessory role in this function (11).
Ontogeny:
There are many theories which have explained the embryological origin of the sternalis muscle. Developmentally, the sternalis represents a remnant of a thoracic rectus muscle which was being derived from the same ventral longitudinal sheet. The nerve supply from the intercostal nerves provided evidence for this derivation. The sternalis is known to be a derivative of the myotonic hypomeres, which form muscles of the ventral and the lateral body walls in the thorax and abdomen. These include the intercostals, the obliquii and the rectus abdominis muscles (12). Other authors have supported the fact that the muscle develops either from the rectus abdominis sheath or from the pectoralis major due to a defect in the muscle patterning. Particularly, in the later case, the defective precursor migration of the prepectoral mass which gives rise to the pectoralis major and the minor muscles may also contribute to the sternalis muscle development, while mechanical disturbances may lead to an atypical clockwise rotation of the muscle fibers (2). The morphological relevance of any muscle reflects upon its innervations, as the nerve supplies that muscle which it is destined to deliver and this is obviously determined at the beginning of its development. Hence, the corresponding embryonic segment may be ascertained (12). But the sternalis muscle innervations were quite enigmatic, implying that the rule of the close relationship between the muscle ontogeny and the innervations may not apply for this muscle. O’ Neil MN and Curran F (13) reported that in 55% of the cases, the muscle was innervated from the external or the internal thoracic nerves and that in 43% of the cases it was supplied by the intercostals nerves, while the remaining cases, it was supplied by both the nerves (2). Clemente (14) considered the sternalis to be a misplaced pectoralis major, while Sadler (15) claimed that the sternalis was represented by the rectus abdominis in the abdominal region and by the infrahyoid musculature in the cervical region; in the thorax, this layer usually disappears, but it occasionally remains as a sternalis muscle. Barlow (8), on the other hand, claimed that the sternalis represents the remains of the panniculus carnosus (13).
Phylogeny:
According to another study, the occurrence of the sternalis was regarded as a demonstration of the atavism of the pectoral musculature in lower mammals (12).
Clinical Importance:
With the use of sophisticated diagnostic and therapeutic tools, there is a need to record and discuss the unusual anatomical variants. They may appear to be pathological, thus making the diagnosis difficult for the radiologist or the surgeon. The sternalis muscle can be easily overlooked during breast surgeries, and it often causes a diagnostic dilemma on mammography or CT scan, as it may mimic a malignant breast mass on mammography (1). The presence of the sternalis may suggest a diagnosis of hernia of the pectoralis major to the examining physician. It may cause breast or chest asymmetry or deviation of the ipsilateral nippleareola complex, while it may coexist with the other pectoralis major defects (2). Also, the sternalis can present alterations on the ECG or occasionally be wrongly interpreted as a mass which requires surgical resection. Its presence may interfere with the sub-muscular pocket dissection when an intraalveolar or submammary approach is used, it can be used to cover the prosthesis in its most medial part and it can also be used for reconstruction surgery after mastectomy (6). Since it has an insignificant function on the anterior chest wall, it may be used as a pedicle flap or as a flap with microvascular anastomosis in plastic and reconstructive surgeries of the head and neck region. Another pertinent alteration which arises from this muscle is the depth at which the internal mammary nodes are irradiated in case of carcinoma of the breast, especially in those lesions which infiltrate the medial quadrants (12). It is true that the solitary existence of this accessory muscle may not present with clinical repercussions. Yet, a notification of its association with several clinical conditions such as anencephaly in 48% and anomalies of the adrenal gland is unavoidable and hence it warrants documentation (12).

Conclusion

The sternalis presents a vertical strap like a muscular variant of the anterior chest wall, with an uncertain teleology, function and origin, which is well known to anatomists, but quite unknown to the clinicians. Hence, this muscle must be amply described in the anatomical literature in order to create and reinforce the much needed awareness about such anomalies among the clinicians. Hopefully, the knowledge of the precise anatomical details of such morphological variants would contribute a great deal towards carrying out successful reconstructive procedures.

References

1.
Kumar H, Rath G, Sharma M, Kohli M & Rani B. Bilateral sternalis with Unusual Left Sided Presentation: A Clinical Perspective. Yonsei Med J 2003; 44(4): 719-22.
2.
Raikos A, Paraskevas GK, Tzika M, Faustmann P, Triadis S, Kordali P et al. Sternalis: an underestimated anterior chest wall anatomical variant. J Cardiothorac Surg 2011; 6: 73. Available at http://www. cardiothoracicsurgery.org/content/6/1/73.
3.
Schulman MR & Chun JK. The conjoined sternalis- pectoralis muscle flap in immediate tissue expander reconstruction after mastectomy. Ann Plast Surg, 2005; 55(6): 672-75.
4.
Jelev L, Georgiev G & Surchev L. The sternalis muscle in the Bulgarian population: classification of sternales. J Anat 2001; 199: 359-63.
5.
Costa VB. O musculo Pre-esternal. Dissertacao de Doutoramento. Lisboa; 1950: 524.
6.
Bhat K MR, Potu BK & Gowda S. Sternalis muscle revisited in South Indian male cadaver: a case report. Cases J 2009; 2: 6318. Available at http://casesjournal.com/casesjournal/article/view/6318.
7.
Novakov SS, Yotova NI, Petleshkova TD and Muletarov SM. Sternalis muscle- a riddle that still awaits an answer short communication. Folia Med (Plovdiv) 2008; 50: 63-66.
8.
Barlow RN. The sternalis muscle in American whites and Negroes. Anatomical Record 1934; 61: 413-26.
9.
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DOI and Others

DOI: JCDR/2012/3580:1950

Financial OR OTHER COMPETING INTERESTS:
None.


Date of Submission: Aug 31, 2011
Date of Peer Review: Oct 30, 2011
Date of Acceptance: Dec 22, 2011
Date of Publishing: May 01, 2012

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